Introduction
Manual of Clinical Nutrition Management III- 2 Copyright © 2013 Compass Group, Inc.
Table III-2: Grading Implications for Practicea
Grade I
Good/strong
Practitioners should follow recommendation unless a clear and
compelling rationale for an alternative approach is present.
Grade II
Fair
Practitioners should generally follow recommendation but remain
alert to new information and be sensitive to patient preferences.
Grade III
Limited/weak
Practitioners should be cautious in deciding whether to follow
recommendation, and should exercise judgment and be alert to
emerging publications that report evidence. Patient preference
should have a substantial influencing role.
Grade IV
Expert opinion only
Practitioners should be flexible in deciding whether to follow
recommendation, although the recommendation may set
boundaries on alternatives. Patient preference should have a
substantial influencing role.
Grade V
Insufficient evidence
Practitioner should exercise judgment and be alert to emerging
publications that report evidence that clarifies the balance of
benefit vs. harm. Patient preference should have a substantial
influencing role.
aAdapted by the Academy of Nutrition and Dietetics from: American Academy of Pediatrics Steering Committee on Quality Improvement
and Management. Classifying recommendations for clinical practice guidelines. Pediatrics. 2004;114:874-877.
Grading information in the Manual appears in parentheses, as seen in the following example:Evidence shows that physical activity at any level, light, moderate, or vigorous, as well as food patterns
emphasizing a diet high in fruits, vegetables, and whole grains is associated with reduced incidence of
metabolic syndrome (Grade II) (1).- Disorders of Lipid Metabolism Evidence-Based Nutrition Practice Guideline. Academy of Nutrition and
Dietetics Evidence Analysis Library. Academy of Nutrition and Dietetics; 2012. Available at:
http://www.andevidencelibrary.com. Accessed January 16, 2013.
Because the Academy’s Evidence Analysis Library is an evolving project, not all sections and
recommendations in the Manual contain grading information. Also, the recommendations that are graded
may be frequently updated as evidence emerges. The practitioner is encouraged to refer to the Academy’s
online library for updates on emerging topics. The grading information is provided to assist practitioners in
making decisions about clinical care and interventions. Grading information should complement clinical
decision-making, not replace sound clinical judgment or expertise.
This section also contains information (eg, medical diagnostic tests or laboratory indexes) that may not
necessarily be mentioned in the nutrition assessment care plan. The evidence that supports the nutrition-
specific information is included to strengthen the dietitian’s role as a participating member of the health care
team. In developing the individual patient care plan, the dietitian selectively discusses the assessment
parameters and interventions that are pertinent to improving the patient’s nutrition care.
In conclusion, the approaches mentioned for each condition are suggestions that should not be interpreted
as definitive nutrition therapy for the given condition. The evidence grades are provided to guide clinical
decision-making and the selection of optimal nutrition approaches. Medical approaches are listed with
medical nutrition therapy approaches to create an awareness of coordinated therapies. Diets approved by
the organization’s medical staff are included in Section I: “Normal Nutrition and Modified Diets”. Condition-
specific protocols, if developed by the organization from the following material, should be approved by the
appropriate committee and placed in the organization’s practice guidelines manual.
Additional information can be obtained at http://www.andevidencelibrary.com
The material in this section is intended:
To provide the dietitian with relevant information that may be considered in the development of the
nutrition care plan.
To form the basis for the development of disease- or condition-specific protocols and nutrition
prescriptions as required by the organization.